DISEASES OF THE DENTAL PULP

CAUSES OF PULP DISEASE:

l. Physical
A. Mechanical
i) Trauma: contact sports/ accident/ fight/ iatrogenic dental
procedures
ii) Pathologic wear
iii) Cracked tooth syndrome
iv) Barodontalgia
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B. Thermal
i) Heat from cavity preparation
ii)Exothermic heat from setting of cement
iii)
Heat conduction by fillings
iv)Sudden changes in temperature from
food stuff (ice cream/ coffee/ ice cubes)
v) Frictional heat during polishing

C. Electrical: galvanic current from dissimilar metallic

fillings.
ll. Chemical:
i) Acidity/ pH of the material
ii) Erosion (acids)
Ill. Bacterial: direct invasion of pulp from caries/ trauma/
developmental grooves/ percolation around a restoration/ extension of
infection from gingiva or by way of blood (microbial colonization in pulp
by blood-borne microorganisms —anachoresis).
CLINICAL CLASSIFICATION OF THE DISEASES OF THE PULP:

1. Inflammatory diseases:
A. Reversible pulpitis
B. Irreversible pulpitis
i) Symptomatic irreversible pulpitis
ii) Asymptomatic irreversible pulpitis
iii) Chronic hyperplastic pulpitis
iv) Internal resorption
2. Pulp degeneration:
A) Calcific degeneration
B) Atrophic degeneration
C) Fibrous degeneration

3. Pulp necrosis
REVERSIBLE PULPITIS:

Is a mild-to-moderate inflammatory condition of the pulp caused by

noxious stimuli in which the pulp is capable of returning to the
uninflamed state following removal of the stimuli.

Symptoms:
• Short, sharp pain lasting for a moment.
• Always specific to a stimulus (sweet/ sour/ cold food/ beverage/ air).
• Pain is instantly removed on removal of the stimulus.
Diagnosis:
• Positive cold test.
• Normal reaction to percussion, palpation & mobility.
• Normal periapical tissue on radiographic examination.
Treatment:
• Prevention
• Removal of noxious stimuli.

Prognosis: favorable if irritant is removedearly.

IRREVERSIBLE PULPITIS:

Is a persistent inflammatory condition of the pulp, symptomatic or

asymptomatic in nature, with the pulp becoming incapable of healing.
Symptoms:
• Severe sharp/piercing/ shooting pain on hot/ cold stimulus/
spontaneous, lingers for several minutes to hours after its removal
(may be intermittent/ continuous).
• Postural/ nocturnal pain —because of increase in intrapulpal pressure
when the patient changes position from a standing posture to that of
a supine posture.
• Pain may be referred to adjacent teeth, temple/ sinuses (upper
posterior tooth)/ ear (lower posterior tooth).
• Sometimes, difficult to localize - offending tooth may respond
severely to heat.
• In later stages, pain is more severe (boring/ gnawing/ throbbing) —
tooth is under constant pressure if there is no outlet (decay/ filling/
packed food into a small exposure in the dentin).
Diagnosis:
• Radiograph may disclose an interproximal cavity not seen visually/
involvement of a pulp horn/ caries under a filling/ deep filling
threatening the integrity of the pulp.
• Positive thermal test (pain persists after removal of stimulus). Hyper-
responsive to cold & electric pulp test.
• Negative response to mobility, percussion & palpation tests.
• Asymptomatic irreversible pulpitis: little/ no pain, except when food is
packed. Delayed response to electric pulp test. If left untreated, may
become symptomatic/ necrotic.
Treatment:
• Complete removal of pulp/ pulpectomy/ root canal treatment.
• Surgical removal of tooth if not restorable.

Prognosis: favorable, if tooth undergoes proper endodontic therapy &

an appropriate post-endodontic restoration.
CH RONIC HYPERPIASTIC PULPITIS:

"Pulp polyp" is a productive pulpal inflammation due to an extensive

carious exposure of a young pulp. Presence of granulation tissue,
covered at times with epithelium, resulting from long-standing, low-
grade irritation.
Cause: slow, progressive carious exposure of pulp.

Symptoms: symptomless, except during mastication,when pressure of

the food bolus causes discomfort.

Diagnosis:
• Seen only in children & young adults.
• Fleshy, reddish pulpal tissue fills most of the pulp chamber/ cavity/
extends beyond the confines of the tooth (bleeds easily, is less
sensitive than normal pulp tissue, but more sensitive than gingival
tissue. No pain on cutting, but pressure transmitted to the apical end
of pulp causes pain).
• Feeble response to cold test & electric pulp tester.
• Radiograph: large, open cavity with direct access to the pulp chamber.
Treatment: elimination of hyperplastic polypoid tissue, followed by
extirpation of radicular pulp (single/ second visit), provided the tooth
can be restored.

Prognosis: favorable, after endodontic treatment & adequate

restoration.
INTERNAL RESORPTION:

Resorption is defined as a conditionassociated with either a

physiologic/ pathologic process resulting in loss of dentin, cementum or
bone.

Internal resorption: is an idiopathic slow/ fast progressive resorptive

process occurring in the dentin of the pulp chamber/ root canals of the
teeth.

Cause: idiopathic/ trauma.

Symptoms:
• Asymptomatic if in the root.
• Crown —reddish area of granulation tissue showing through resorbed
area of crown —'pink spot'.

Diagnosis:
Radiograph: change in the appearance of the wall in the root canal/
pulp chamber —round/ ovoid radiolucent area
Treatment: endodontic treatment (obturation using plasticized gutta-
percha). If root is perforated —MTA is used to repair the defect.

Prognosis: best before perforation of crown/ root occurs. In case of a

crown-root perforation, prognosis depends on access to perforation for
surgical repair.
CALCIFIC PULP DEGENERATION:

May be due to persistent, mild irritation in teeth of younger people

(infection/ caries/ filling). Part of pulp tissue is replaced by calcific
material (pulp stones/ denticles) within the pulp chamber/ root canal.
Calcific degeneration (rapid deposition of hard tissue) of complete
pulp space as a sequelae to a traumatic injury —calcific
metamorphosis.
Calcified pulp: laminated structure (onion skin) attached/ unattached
within body of pulp.
Initially, no symptoms (harmless). Later, tooth may become discolored
& the pulp does not respond to stimulation.
Radiographic diagnosis: obliteration of pulp space/ intracanal
radiopacity similar to surrounding dentin.
Management:
• Asymptomatic tooth: esthetic management (full-coverage/ laminate
restoration).
• Symptomatic tooth: endodontic therapy using a microsurgical
retrograde approach.
PULP NECROSIS:

Death of pulp (partial/ total).

ed
Cause: any noxious insult injurious to the pulp (bacteria/ trauma/
chemical irritation).

Symptoms:
• Tooth discoloration
• Partially necrosed tooth may respond to vitality tests.

Diagnosis: asymptomatic death of pulp/ history of trauma/ severe pain

lasting from a few minutes/hours/ large cavity/filling/ open approach
to a root canal & a thickening of the periodontal ligament
Treatment: root canal treatment.

Prognosis: favorable, if endodontic treatment is proper.